A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses’ activities in daily practice regarding antibiotic use

Abstract Background Antimicrobial stewardship (AMS), the set of actions to ensure antibiotics are used appropriately, is increasingly targeted at all those involved in the antimicrobial pathway, including nurses. Several healthcare organizations have issued position statements on how bedside nurses can be involved in AMS. However, it remains unclear how nurses, in reality, contribute to appropriate antibiotic use. Objectives To systematically search the literature to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, in relation to the activities proposed by the aforementioned position statements. Methods We searched MEDLINE, Embase, CINAHL and grey literature until March 2021. Studies were included if they described activities regarding antibiotic use performed by bedside nurses. Methodological rigour was assessed by applying the Mixed Method Appraisal Tool. Results A total of 118 studies were included. The majority of the proposed nurses’ activities were found in daily practice, categorized into assessment of clinical status, collection of specimens, management of antimicrobial medication, prompting review and educating patient and relatives. Nurses may take the lead in these clinical processes and are communicators in all aspects of the antimicrobial pathway. Patient advocacy appears to be a strong driver of bedside nurses’ activities. Conclusions Nurses’ activities are already integrated in the day-to-day nursing practice and are grounded in the essence of nursing, being a patient advocate and showing nursing leadership in safeguarding the antimicrobial treatment process. An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial pathway. Educating, engaging and empowering nurses in this already integrated role, could lead to a solid, impactful nursing contribution to AMS.


Introduction
Antimicrobial resistance (AMR) is an increasing global threat. 1,2It is estimated that 33 110 patients die per year in the EU alone as a result of infections caused by resistant bacteria. 3One of the strategies to mitigate AMR is to use antibiotics in an optimal way and the set of actions to ensure this optimization is known as antimicrobial stewardship (AMS). 47][8][9][10][11][12][13] In 2015, Olans et al. 14 used a modified Delphi process with 10 nurse educators to identify several areas in which nurses should be educated as a prerequisite for adequate participation in AMS programmes.These consensus-based activities were also used to further elaborate the potential contribution of nurses 6,15 and became a solid foundation to the position papers of several international nursing and healthcare organizations.
In 2017, the International Council of Nurses (ICN) published its revised Position Statement on the role of nurses in combatting AMR. 16Other healthcare organizations such as American Nurses Association (ANA), CDC, Australian Commission on Safety and Quality in Health Care (ACSQHC), European Federation of Nurses (EFN) and WHO followed, 7,[17][18][19] acknowledging nurses for the important role they can play in protecting the 'power of antibiotic medication'. 16,20These position papers suggest that nurses may contribute by assessing and monitoring patients' clinical status, participating in diagnostic culture and antimicrobial treatment management, and educate patients and families (Figure 1). 21,22owever, it remains unclear how bedside nurses in their daily practice perform these proposed activities and how this relates to their role as described in the position papers.
This integrative review aims to describe the activities bedside nurses perform regarding antimicrobial use in daily practice.

Methods
This integrative review (PROSPERO registration CRD42020161713) was conducted according to the methodology of Whittemore and Knafl, combining both quantitative and qualitative studies to create a holistic understanding of the phenomenon under study. 23[19]21,22 These recommendations were summarized into five domains (Table 1).The review is reported according to the PRISMA guidelines. 24

Literature search
In March 2020 (and updated in March 2021), a systematic literature search was conducted in the following databases, from 2000 and onwards: PubMed/MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL) and Excerpta Medica database (Embase).We developed search strings containing the keywords 'antibiotic/antimicrobial', 'stewardship/plan/program/policy' and 'nurse' or synonyms of these keywords ( File S1, available as Supplementary data at JAC Online).Reference lists of included articles were handsearched for additional studies, performing both forward and backward searches.Literature reviews were handsearched for additional eligible primary studies.
Since the topic of nurses' involvement in antibiotic use is relatively young (first publication on this topic is dated 2011), 9 we also performed an extensive grey literature search, using Web of Science, conference proceedings and websites of relevant professional organizations such as CDC, ESCMID, the Association for Professionals in Infection Control and Epidemiology (APIC) and The Society for Healthcare Epidemiology of America (SHEA), to identify additional unpublished studies. 25,26A simplified search string using keywords 'antibiotic/antimicrobial' and 'nurse' was used.Since conference abstracts are currently published in supplements of peer-reviewed journals and therefore were included in the updated search, we did not perform an additional search of the grey literature.

Eligibility criteria
We included primary studies if they described activities regarding antibiotic use performed by bedside nurses in all healthcare settings.Bedside nurses were defined as nurses who perform direct patient care activities (Registered Nurses, Licensed Practical Nurses, Specialized Nurses, Nurse Specialists, and equivalents of those). 27,28Studies describing activities by nurse prescribers were excluded since prescribing antibiotics is not a regular activity of bedside nurses 29 and these prescribing rights require additional registration. 30,31We made no restrictions regarding the methodology of the primary studies.Also, we included studies in both inpatient and outpatient settings, as well as settings in high-, lowand middle-income countries.We applied no language selection.If the original language was not fully mastered by the researchers, we translated the article by using an automated translating service.
For the grey literature search, we applied the same eligibility criteria.Additionally, if a conference abstract was subsequently published as a journal article, this article was included in the peer-reviewed literature screening process. 32If a conference abstract had insufficient data, the  • Correctly taking cultures (avoiding contamination, unnecessary sampling/maintaining specimen quality) 7,19,21,22 Communication and documentation of results

Management of antimicrobial medication
Allergy assessment • Take and document allergy 17,19,21,22 Administration of antimicrobial medication 16,17 • Medication reconciliation (including discharge) 7,18,22 • Timely administration (including first dose of antibiotics if patient has sepsis) 7 • Respect medication safety principles (5 'rights' of medication administration)   • Inform patients on antibiotic timing, interaction with food, medication compliance 18,22 • Educate patients on adverse events 22 • Educate patients on when to ask for review if concerned 7 • Give information on which signs and symptoms to share with healthcare provider 21 • Give information on how to return leftover medication to pharmacy 22 Encourage patient and peer professional interactions on antimicrobial prescription and therapy 22 Systematic review first author was contacted to request additional information to facilitate the inclusion decision. 32

Study selection/data extraction
Two researchers independently screened title and abstract of both peerreviewed (M.H., M.B.) and grey literature results (J.S., M.B.), as well as the selected full-text articles.In case of disagreement on eligibility, discussion followed until consensus was reached.Any discrepancies between reviewers were resolved through consensus or consultation with a third reviewer.The screening and selection process was aided by Rayyan software. 33Data regarding study specifics and nurses' activities were independently collected using Excel software by one researcher (M.B.), of which 50% was double-checked (J.H.).The following variables were collected: author, year of publication, aim of study, study design, characteristics of the participants, setting, country of study origin, nursing activities related to antibiotic use.

Quality appraisal
The selected peer-reviewed literature was critically appraised by two researchers (M.B., C.B.) independently, using the Mixed Method Appraisal Tool (MMAT) by Hong et al., 34 which is applicable for different methodologies.However, methodological quality was not used as an exclusion criterium.Systematic review nurses' activities.These activities were then compared with the proposed activities as described by the healthcare organizations (Table 1).

Main findings
Nurses' activities are presented in relation to the summary of proposed activities (Table 2).

Domain 1-Bedside nurses' assessment of clinical status
Overall, four of the six aspects of the first domain were addressed by studies describing how nurses assess the patient's clinical status related to antibiotic use in daily practice.
The first aspect mentions that nurses should assess, diagnose and identify appropriate precautions to prevent transmission of microorganisms.Studies describing this activity in relation to AMS were not found.
,73,76,77,86,87,91-93,98,99,104,105,107,113,114,121,128,141,142 Thirteen studies also described how nurses are in the lead by taking predetermined follow-up actions on their clinical assessment, guided by decision tools, algorithms and protocols, 49,50,53,55,61,77,87,91,99,121,128,141,142 such as a neonatal sepsis calculator.55,87,121,141,142 Three studies mentioned that nurses, undertaking these actions, are advocating for the best care for their patients.40,104,107 Twelve studies described the third aspect, how nurses, in daily practice, identify whether patients have symptoms that justify diagnostics.39,50,57,61,77,104,105,107,113,115,122,128 For example, Zabarsky et al. 113 described that nurses in an LTCF often initiate urine cultures, based on their clinical judgement.
The fourth aspect addresses that nurses monitor and report the clinical status of a patient.Six studies describe this activity in daily practice. 50,88,93,107,110,128Aspect five, how nurses monitor treatment outcomes in daily practice, was described by four studies. 40,49,93,103Nurses' monitoring of oral intake capacity (aspect 6) was not found.
2,150 Nurses, in daily practice, take the lead in communication in different ways, e.g. in an LTCF by recommending treatment based on signs and symptoms 49 or communicating patients' clinical status in nurse-driven AMS rounds. 68

Domain 2-Collection of specimens
The second domain targets how nurses contribute to AMS by collecting diagnostic specimens.All four aspects were described in daily practice.
The first aspect, nurses taking cultures before administering antibiotics, was described in four studies. 70,91,96,119One study described that this sampling process was nurse-led, as part of triage standing orders. 91he second aspect addresses that nurses should take cultures correctly.Nurses upheld this standard in 23 studies. 39,46,50,57,61,63,66,75,77,91,93,96,99,104,108,113,115,120,122,124,127,133,146 Fur of these studies also described that nurses initiated a discussion with the prescriber about the necessity of the cultures 61,115,122 or initiated sampling. 113Three studies mentioned that, in daily practice, nurses communicate or document orders for cultures or document the specimen's source. 50,93,108he third aspect concerns nurses' monitoring of culture results.4,151 One study reported that nurses led a culture follow-up process in paediatric patients, where, after physician review, nurses communicated negative culture results to the parents, together with the physician's recommendation to discontinue antibiotics. 95stematic review

Systematic review
The fourth aspect describes that nurses should timely inform the prescribers about the culture results.Nine studies mention this nursing communication in daily practice. 45,50,54,77,94,95,104,130,134Three studies reported that nurses go one step further, by appraising the results and, if deemed necessary, alarming the physician. 54,95,104One study reported that nurses advocate for patients' best interests when communicating these results. 107n the summary of proposed nurses' activities, there was no suggestion that nurses, in their daily process, should initiate sample collection for diagnostic purposes.However, nurses taking the lead in daily practice were described in 11 studies. 49,50,57,77,91,97,99,104,105,107,113In three studies this was considered a bad practice, especially related to UTI diagnostics. 77,104,105

Domain 3-Management of antimicrobial medication
This domain (Table 2) covers nurses' activities related to the management of antimicrobial medication and includes 10 aspects, of which 9 were described in the literature.
The first aspect describes that nurses should take and document allergies for antibiotics, which was described as daily practice by 12 studies. 36,41,47,48,64,66,100,106,110,126,129,145Three of these reported that nurses take the lead in this, either by using a decision tool or algorithm when obtaining an allergy history 129,145 or by participating in rounds with a hospitalist discussing antibiotic allergies. 100dministration of antimicrobial medication, the second aspect, was the second most frequently described nursing activity in daily practice (n = 29). 10,35-37,40-42,44,49,51-53,64,69,71,78-80,[83][84][85]92,93,96,110,116,118,125,148 Three studies also described that nurses, in relation to the medication administration process, perceive themselves as advocates for their patient, ensuring that the patient receives the best possible care. 40,41,83 Communication aboutantimicrobial medication was seen as a vital element in daily practice, as was emphasized by Rout et al. 93 in a study among ICU nurses.
The third aspect, medication reconciliation by nurses, was not covered in the studies.
Aspect four, timely administration of antibiotics by nurses, was described by 20 studies. 40,41,45,53,65,71,79,83,85,91,92,94,96,102,119,121,138,143,144,149 T Broom et al. 41 described that nurses, fearing adverse clinical outcomes and driven by patient advocacy, timely administered antibiotics without pharmacist approval.In a study in an Australian Emergency Department, nurses reported that poor interprofessional communication negatively impacted the timely antibiotic administration. 65egarding aspect five, nurses' activities related to medication safety, the five Rs ('the right patient, right drug, right dose, right route, and the right time' protocol), were mentioned as a daily care activity in 16 studies. 40,41,45,49,53,56,66,67,70,81,83,85,93,94,106,110he sixth aspect concerns how nurses ensure that the incidence of missed antimicrobial doses is reduced. Wong et al. 110 reported that nurses take the lead in this by 'smoothing' the process of antibiotics, e.g. by verifying whether the pharmacy has been contacted.Three studies mentioned 'brokering' (ensuring the antibiotic is available) as nursing activity, which was driven by patient advocacy. 40,71,85he seventh aspect of the domain is how nurses (help) comply with surgical prophylaxis indicators, such as the correct timing of antibiotic administration before surgery.Five studies mentioned this nursing activity in daily practice. 36,84,109,117,140Baker et al. 117 described how nurses lead this preoperative process, by using an algorithm to evaluate the correctness of the preoperative antibiotic.
The eighth domain aspect addresses how nurses, in daily practice, document the indication and duration of antimicrobial treatment.Three studies described this nursing activity in daily care, 93,131,139 of which Lo et al. 139 describe a nurse-led AMS intervention to encourage the medical team to document indication and planned treatment duration.
Documentation of administered antimicrobial medication by nurses in daily practice (aspect nine) was mentioned in four studies. 35,64,83,93he tenth aspect concerns nurses' monitoring of adverse events of antimicrobial treatment.Three studies described this activity in daily practice. 50,62,74our additional bedside activities were found.Nurses participate in treatment initiation, which may have different gradations.Eight studies described this nursing activity in daily practice, 40,45,49,73,77,88,90,105 which ranges from selecting and starting antibiotics based on an algorithm, 77,88 recommend treatment based on clinical assessment 49 or give guidance to prescribers in what the nurse thinks is the best decision for this patient. 40One study mentioned that nurses may stop antibiotic treatment when the cultures are negative. 77Nurses also monitor therapeutic levels of the antibiotic treatment. 48dditional non-bedside AMS activities performed by nurses in daily practice were found in eight studies. 45,47,59,60,72,76,104,110ursing participation included developing antimicrobial prescribing guidelines, 45,47 ensuring implementation and use of protocols and guidelines, 45,60,110 promoting guideline adherence, 76,104 teaching appropriate use 45,72 and participating in audits. 45,59

Domain 4-Prompting review
Prompting, 'encouraging or reminding someone of something', 153 contains seven aspects, all of which were found.
2,136 Prompting may be an act of nursing leadership (described in 14 studies 40,42,44,49,58,60,68,71,72,80,82,106,110,136 ) but was also considered an act of patient advocacy, striving for the best possible care. 40,58,60,71,72,104,110,136he second aspect describes that nurses can monitor treatment duration and assess the need for continuation on Day 3 and/or Day 7. Twelve studies described this daily practice, 40,44,45,48,59,80,89,92,93,101,103,123 of which four studies emphasized the importance of this nursing role. 44,89,101,103According to one study, this is how they advocate for their patients. 40he third aspect, prompting review of the potential for IV-to-oral switch, was described by three studies. 10,71,96No study Systematic review detailed the fourth aspect, where nurses arrange and coordinate follow-up for review of antibiotic treatment.
Prompting review of drug/bug mismatch, time-outs and antibiotic de-escalation (the fifth aspect) was described by six studies, 42,68,71,93,104,117 where in five studies nurses took a leading role. 42,68,71,104,117Rout and Brysiewicz 93 added that, by doing this, nurses are acting on behalf of their patient.
The sixth aspect, prompting assessment of the suitability of the patient for outpatient parenteral antibiotic therapy (OPAT), was described in two studies. 10,96The seventh aspect, prompting discussion about antibiotic therapy at the end of life, was described by two studies, 57,58 where nurses see their role primarily as patient advocates and show leadership, especially in relation to AMS.
Four additional bedside nurses' activities were described.Firstly, according to five studies, bedside nurses lead and participate in AMS rounds where antibiotic treatment is discussed in multidisciplinary cooperation. 68,93,100,101,123econdly, nine studies reported that nurses prompt prescribers to start antibiotic treatment for their patients, 40,43,49,58,73,98,105,107,112 thus showing leadership in daily practice (n = 4) 40,43,105,112 or advocating for their patients (n = 2). 43,107s the third additional aspect, two studies mentioned that bedside nurses discussed treatment with the prescriber, based on the diagnostic results, 72,104 although the prescribers were not always willing to listen. 104astly, two studies indicated that bedside nurses, in daily practice, led by prompting prescribers to document indication and duration of antibiotic treatment, thus advocating for their patients. 58,139

Domain 5-Patient communication, education and information
This domain contains seven aspects, of which five were described in daily practice.
The first aspect, patient and family education on appropriate use, was described in six studies 45,47,48,86,110,132 as a nursing activity in daily practice.
The second aspect describes how nurses educate and inform patients on how to take their antibiotics (timing, interaction with food, medication compliance), which was reported as daily practice in nine studies. 45,48,67,72,85,110,111,135,147he education of patients on adverse events or when to ask for review when concerned (aspects three and four) were not found in the literature.Only one study mentioned the fourth aspect, that nurses give information on which signs and symptoms to share with healthcare providers. 86The fifth aspect, how nurses, in daily practice, educate patients on how to return leftover medication, was not addressed.
The sixth aspect, how nurses can encourage patient and peer professional interactions on antimicrobial prescription and therapy, was mentioned in one study. 58dditional activities of bedside nurses in this domain were found in two studies, where bedside nurses give patients education on how to correctly take cultures 108 and where nurses communicate the negative culture results to the patient and family and give the physician's advice to stop antibiotic treatment. 95

Discussion
This review aimed to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, comparing them with the proposed nursing activities in the position statements by professional healthcare organizations (ICN, ANA, CDC, ACSQHC, EFN, WHO).We found that nurses, in daily practice, without question, already perform the majority of the proposed activities throughout the entire antimicrobial pathway.
These results nuance the findings of previous reviews, which stated that nurses remain disconnected from AMS activities 154 or need improvement in communication skills regarding AMS, 155,156 e.g. to question the prescriber.
Importantly, we also found three overarching intrinsic elements of these nurses' activities that were not explicitly mentioned in the position papers.First, nurses' activities appear to be grounded in patient advocacy, 'striving for the best possible care for their patient'. 157Several attributes of patient advocacy, 158 such as safeguarding the patient from errors, providing information about the patient's diagnosis and treatment, and mediating (being a liaison between patient, family and healthcare workers), are clearly recognizable throughout nurses' contribution to AMS, e.g. as nurses prompt review of the antimicrobial treatment. 40,58,60,71,72,104,110,136Patient advocacy may be a strong motivator for participation in AMS, which was also acknowledged in recent reviews by Gotterson et al. 154 and van Huizen et al. 156 Secondly, nurses, in daily practice, take the lead in many parts of the antibiotic treatment process, e.g. by initiating culture sampling 49,50,57,77,91,97,99,104,105,107,113 or participating in AMS rounds. 68,93,100,101,123This clinical (often informal and hidden) 159 bedside leadership may be an expression of the central position of nurses in patient care. 160The coordination of the healthcare trajectory 161 is a contribution that is not always visible, recognized or valued. 162,163By uncovering this dimension of nursing leadership, we highlight a complementary building block for AMS in effective and safe patient care. 164,165hird, we found that communication (including documentation of information) is an important aspect of the nurses' contribution 65,93,104,107,114 and interwoven in all aspects of the antimicrobial pathway.In an overview article on the 'past, present and future of nurses and AMS', Olans et al. 166 considered the nursing profession as a central hub in the AMS communication web, updating those who provide care as well as patients and their caregivers.
Appropriate antimicrobial use is considered a patient safety priority 167 and part of providing high-quality patient care.Since effective interdisciplinary communication is essential for providing high-quality care, 168,169 all members of the multidisciplinary healthcare team should continue to invest in effective communication throughout the antimicrobial pathway.To strengthen the team communication, barriers such as physician and nurse hierarchy 94,104,106 or lack of knowledge and experience regarding antibiotic use 13,94,106,154,156,[170][171][172] should be addressed.
The findings of this review highlight that nurses' contribution to AMS is already grounded in daily practice although nurses may not recognize their daily practice as contributing to AMS.Nurses' actions are targeted at patients well-being and ensuring a smooth care trajectory, while not specifically aimed at reaching AMS goals.

Systematic review
However, as a collateral benefit, these nursing goals align with the AMS goals of effectively treating infections, protecting patients from harm caused by unnecessary antibiotic use (e.g.toxic side effects, Clostridioides difficile infection) with the ultimate goal to prevent the development and spread of AMR. 21s a first step to enhance the nursing contribution to AMS programmes, an educational intervention can be applied.Education, as an implementation strategy, has been shown to improve AMS behaviour such as recognizing the appropriate response to treatment, communicating promptly when receiving laboratory results and collaborating with the interprofessional healthcare team to optimize antimicrobial treatment. 173As an example, Arnold et al. 174 described an educational intervention aimed at nurses, to support them with clinical reasoning and communication process concerning suspected urinary tract infections (UTIs) in nursing home patients.This intervention importantly reduced the rate of antibiotic prescriptions and inappropriate treatment.
However, education (on its own) does not necessarily translate into change of practice. 175To fully live up to the stewardship role, nurses also need to apply leadership, to be committed to speaking up about issues related to the antimicrobial treatment.Olans et al., 166 in a summarizing paper, described that true multidisciplinary collaboration involving nurses has not yet been achieved and should be improved by emphasizing the collaborative character of AMS.Nurses need to 'take a seat at the table', while being acknowledged as a valuable and visible contributor.However, prior to establishing an effective partnership between prescribers and nurses, some practical issues should be addressed, such as knowledge gaps, time constraints and uncertainty about the nursing scope of AMS practice. 176Clarification of professional roles will increase mutual respect for the unique contribution of all those involved in AMS, which is essential for effective collaboration. 177Working in an environment where AMS is perceived as a collaborative effort and the responsibility of all those involved in the patient careway, is crucial for establishing a meaningful nursing contribution. 52,71Overall, nurses make up almost 50% of the global nursing and midwifery workforce 178 and by involving nurses in AMS activities, the potential to achieve and consolidate the AMS goals may be unprecedented. 179o realize this potential and enable nurses to fully contribute to AMS, whether in high-, middle-or low-income countries, a tailored approach is needed to support nurses' contribution. 8,180,181lobal standards, guidelines and toolkits are already available for this purpose, e.g. the 'WHO Competency Framework for Health Workers' Education and Training on Antimicrobial Resistance', 19 the 'Antimicrobial Stewardship Programmes in Health-Care Facilities in Low-and Middle-Income Countries: a WHO Practical Toolkit', 182 and the WHO's 'Health Workers' Education and Training on AMR: Curricula Guide'. 183uture research, as advised by WHO in the Global Research Agenda on AMR, should investigate strategies to optimize antimicrobial therapy. 184Research focused on how to engage and sustain nurses' contribution in AMS, as well as how to optimize the nurse-physician collaboration in AMS, can be seen as a very promising endeavour.
This review has several strengths.We performed an extensive and broad search and included grey literature, preventing the effects of publication bias. 185We included studies from all healthcare settings, which gives a broad understanding of nurses' activities in both intramural and extramural care pathways showing the potential for further nursing engagement.
A limitation is that, due to the search strategy connected to AMS, studies with no apparent link to appropriate antibiotic use (e.g.studies that only describe nurses' contribution to UTI diagnostics without highlighting AMS potential), were not included.Yet, we feel that due to the extent of our search results, this did not impact the identification of the most common activities of nurses in daily practice.
Secondly, as we focused in our review on the activities that bedside nurses perform with regard to appropriate antibiotic use, we did not address nurses with prescribing rights.These expert nurses form a special group of nurses who have undergone additional specialist training to acquire the competencies to prescribe medication.They are also bound by organizational and jurisdictional regulations. 30,31,186

Conclusions
Nurses' activities, as proposed by international healthcare organizations, are already integrated into day-to-day nursing practice.These activities, throughout the entire antimicrobial treatment pathway, are grounded in the essence of nursing, being a patient advocate and showing leadership in safeguarding the antibiotic treatment process.An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial process.Educating, engaging and empowering nurses to embrace and acknowledge their contribution to AMS could lead to a solid, impactful contribution to safe healthcare across the globe.
Reduce incidence of missed antimicrobial doses 7 • (Help) comply with surgical prophylaxis quality indicators 22 Documentation of antimicrobials 7 • Document the indication & duration of antibiotic treatment 7 • Documentation of administered antimicrobials 19 Monitor adverse events, e.g.diarrhoea 7,17,19,22 Domain 4 Prompting review Prompting review of antimicrobial treatment 21 • Prompt prescribers to review antibiotic treatment (not further specified) • Monitor treatment duration: need for continuation (Day 3 or/and Day 7) 22 • Prompt review of potential for IV-to-oral switch 17,21 • Arrange & coordinate follow-up for review of antibiotic treatment 7 • Prompt review of drug/bug mismatch, time-outs, antibiotic de-escalation 17,21 • Prompt assessment of suitability of patient for OPAT 22 • Prompt discussions on issues concerning antimicrobial therapy at the end of life with patients, carers and other members of the healthcare team as part of planning for end-of-life care 7 Domain 5 Patient communication, education & information Educating patient and family/caregivers (including discharge information) • Educate patient on appropriate use 18,21

Table 1 .
Summary of bedside nurses' activities with regard to (appropriate) antibiotic use (as proposed by guidelines and position papers) Monitor treatment outcomes16• Monitor capacity for oral intake17,21 Assessment of clinical status• Identify source of infection (assess, diagnose & identify appropriate precautions) 16,17,19 • Identify and escalate patients with signs of acute deterioration or infection 7 • Identify if patient has symptoms that justify diagnostics (e.g.does patient have symptoms that justify urine culturing?) 21Monitoring clinical status of the patient • Monitor and report daily clinical status, including e.g.laboratory results (e.g.renal function test results) 17,19,22 • 7

Screening Included Eligibility Identification
All studies were uploaded in Atlas.ti 8 Windows software.Relevant text fragments were highlighted, coded and categorized into networks of comparable